Changing Patient Attitudes Towards
Exercise Therapy
Sarah Dean
Sarah Dean’s position is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula. The views
expressed in this presentation are those of the author(s) and not necessarily those of the NHS, the NIHR or the UK Department of Health.
Acknowledgements
OPAL Hagen, S., McClurg, D., Glazener, C., Abdel-Fattah, M., Wael,
A., Bugge, C., Dean, S., Norrie, J., Hay-Smith, EJC., Kilonzo, M.,
Elders, A., McPherson, G., McDonald A M, Booth, J., Buckley, B.,
Guerrero KL., Wilson, LE.
e-coachER Adrian Taylor, Rod Taylor, John Campbell, Colin Greaves,
Sarah Dean, Kate Jolly, Lucy Yardley, Mary Steele, Paul Little, Nana
Anokye, Nanette Mutrie, Anthony Woolf, Josephine Erwin, Ben Jane,
Jane Vickery & Wendy Ingram, Liz Ford
ReTrain Sarah Dean, Raff Calitri, Anthony Shepherd, Leon Poltawski,
Martin James, Rhoda Allison, Shirley Stevens, Meriel Norris, Anne
Spencer, Rod Taylor, Anne Forster
Free Ben Darlow, Anthony Dowell, G. David Baxter, Fiona Mathieson,
Meredith Perry, and Sarah Dean
Layout of talk
Behaviour Change Techniques (BCTs)
Using a Behaviour Change model
Health Beliefs, Attitudes and Behaviour
Existing research evidence
Current research projects
Common theme of how to promote exercise
Behaviour Change Techniques (BCTs)
The Information Motivation
Behavioural Skill Model
Fisher et al, 2003
NB There are many theories and models for understanding
health behaviours, but no one theory explains it all!
The Information Motivation
Behavioural Skill Model
Fisher et al, 2003
Health Beliefs & Attitudes
• Beliefs - links with information, knowledge &
understanding about health
– Lay theories
– Sense making
– Cognitions, representations or perceptions
• Attitudes - links with mood and motivation
– Positive
– Neutral
– Negative
Patient Beliefs can be very powerful drivers of behaviour
Beliefs about cause and attitudes towards treatment benefits
Beliefs about Myocardial Infarction (MI) and Cardiac Rehabilitation Petrie, K. J., Cameron, L. D., Ellis, C. J. et al 2002.
• Randomised Control Trial with 56 patients with MI to either an
intervention designed to alter their perceptions about their
MI, or to usual care from rehabilitation nurses.
• 3 intervention sessions:
– the pathophysiology of MI,
– patient’s beliefs, misconceptions,
– developing a plan to minimise future events, advice on
exercise, diet and return to work, writing / reviewing plans
for self-management, symptom management, side effects
of drugs, reinforcing need to take medication regularly.
Beliefs about MI and Cardiac Rehabilitation Petrie, K. J., Cameron, L. D., Ellis, C. J. et al 2002; see also Broadbent et al 2009.
• Outcome measures: illness perceptions & return to work.
• At 3 months, significant success in changing patient’s belief to a more positive and controllable view of MI compared to control patients.
• Intervention group had a shorter delay in return to work compared with the control.
Beliefs about MI and Cardiac Rehabilitation
Regular exercise or exercise with education and
psychological support can reduce the likelihood of dying
from heart disease. RR of mortality after 12 months = 0.87
[95% CI 0.75, 0.99]. (Heran et al. Cochrane Review 2011)
Establish people's health beliefs and their specific
illness perceptions before offering appropriate lifestyle
advice and to encourage attendance to a cardiac
rehabilitation programme. [NICE 2013]
Offer cardiac rehabilitation programmes designed to
motivate people to attend and complete the programme.
Explain the benefits of attending. [NICE 2013]
Clinician health beliefs and attitudes –
powerful drivers of patient behaviour
Eur J Pain 16 (2012) 3–17
Do we have risk averse beliefs that we transmit to our
patients with low back pain?
Our concerns about missing a ‘red flag’ (serious spinal
pathology) may inadvertently mean we give messages that
create ‘yellow flags’ (e.g. fear avoidance) in our patients
Clinician beliefs and attitudes – why
so powerful?
Darlow, Dowell, Baxter, Mathieson, Perry & Dean
The Enduring Impact of What Clinicians
Say to People With Low Back Pain 2013
We act as ‘credible sources’ (BCT 74) of information
Patient: “This input improves my quality of life hugely and I’m
very grateful for the chance to do this. It’s like having
somebody walk beside you”
Trust and credibility are a good foundation for facilitating
exercise
Message 1: Check out patient health
beliefs (and our own beliefs)
Fisher et al, 2003
Health Beliefs
about the condition
& expectations of
outcome / treatment
benefit
Information and beliefs are not enough
‘knowing isn’t doing’
Poor adherence to exercise may limit long-
term effectiveness (Jordan et al 2010)
Low back pain (e.g. Sluijs et al, 1993)
Cardio vascular rehab (e.g. Jurkiewicz et al, 2011)
Urinary incontinence (e.g. Borello-France et al, 2013)
Mild to moderate intensity exercise
150 mins per week
ACSM guidance 2011 (www.acsm.org accessed May 2015)
The Information Motivation Behavioural Skill
Model
Fisher et al, 2003
Can adding internet support help
patients with long-term metabolic,
musculo-skeletal and mental
health conditions to access GP
exercise referral schemes and
remain regularly active?
Users learn about setting SMART goals to increase moderate intensity physical activity
and have examples
and stories linked
to travel, leisure
and domestic
activities.
‘Steps to Health’
• Participants are invited to go through 9 ‘steps to health’ which are designed to help them increase their level of physical activity.
Goal setting as a ‘cornerstone of rehab’
• Summary of issues-
see Levack & Dean in Chapter 4
Interprofessional Rehabilitation 2012
• Cochrane review- updating the evidence Levack, Siegert, Dean, McPherson, Hay-Smith & Weatherall. Goal setting
in rehabilitation (Protocol). Cochrane Database of Systematic Reviews
2012, Issue 4.
See also: Siegert, R.J. & Levack, W.M.M. (Eds) (2014) Rehabilitation Goal
Setting: Theory, Practice and Evidence, CRC Press
BCT Group: Goal Setting and Action Planning
BCTs in this group are:
• Problem solving
• Goal setting (behaviour)
• Goal setting (outcome)
• Action planning
• Review behaviour goal(s)
• Review outcome goal(s)
• Behavioural Contract
Source: BCT Taxonomy (v1) Michie et al 2013
Behavioural Contract and Commitment
• Make sure patient is involved in all goal setting and that
they understand and agree in writing to all short term
and long term goals and verbalise their commitment.
1) Clinician: “please will you sign (initial) this sheet where
I have written down the goal we have just agreed”
2) Ask the person to make statements indicating strong
commitment to change the behaviour:
3) Patient: “I will do my exercises ….. x times per week…”
Message 2: Check attitudes towards
exercise; make use of the suite of BCTs to
enhance motivation
Fisher et al, 2003
Goal Setting, Action
Planning and
Behavioural Contracts
On-going exercising - still a problem
Initial take up (often in a supported treatment
setting) does not translate into daily routine
People relapse and don’t resume their
exercises
Need different strategies and skills for the
different phases of exercise
The Information Motivation Behavioural Skill
Model
Fisher et al, 2003
Compares usual (basic) pelvic floor exercises
versus pelvic floor exercises with biofeedback
Aim to intensify the exercise intervention
BCTs to operationalise the use of
Biofeedback to increase intensity of, and
adherence to, pelvic floor exercises http://www.hta.ac.uk/project/2986.asp
BCT 23: Rehearsal & Practice of Skills
• A pelvic floor muscle contraction is a physical
(neuromotor) skill
BCT 14 : Biofeedback
• Women highly value knowing that they can
perform a correct contraction – skill mastery
Rehabilitation Training after Stroke (ReTrain): A Pilot Randomised Control
Trial (RCT) Sarah Dean, Raff Calitri, Anthony Shepherd, Leon Poltawski, Martin James, Rhoda Allison,
Shirley Stevens, Meriel Norris, Anne Spencer, Rod Taylor, Anne Forster
This poster presents independent research funded by the Stroke Association and supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula. The views expressed in this poster are those
of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
ReTrain programme
ReTrain is based on the ARNI programme
(www.arni.uk.com)
Improving functional mobility via personalised
negotiated goals with exercise professionals
ReTrain enhances function via task related
practice, strengthening training and
compensatory strategies
Develops self management skills and instils a
commitment for regular exercise
Funded by
the:
On-going management BCT
• Reinforce by praising progress or
adoption of any self-management.
• Teach the patient self-
assessment skills so they know
when to focus on their own
exercises versus how and when to
seek further help.
• Analyse factors influencing
exercise behaviour to overcome
barriers or increase facilitators
Social reward
Self-monitoring
of behaviour
Social support
(practical)
Problem solving
(includes coping
with relapse)
Message 3: Don’t forget to add the skills
training
Fisher et al, 2003
Skills for doing the
exercises and for self
managing on-going
exercises
What next?
• Explicit use of BCTs in clinical practice
• Cochrane review on goal setting Levack et al
• On-going research
– OPAL
– ecoachER
– ReTrain
– Measuring exercise (adherence) Bollen, Dean et al 2014,
BMJ Open.
Summary of talk
Shown how we can use BCTs to change patient beliefs
and attitudes towards therapeutic exercise and give
them the skills to uptake, adopt and maintain their
exercises
Quality information – check beliefs
Motivational strategies – promote positive attitude
Skill training – for exercises & for self-management
Evidence informed practice combining patient beliefs
with clinician expertise and context specific factors